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MVC-AACN Newsletter FALL 2015 30th Anniversary Celebration! Our Chapter celebrated 30 years this year with a party at Lenzi’s on September 17th. A good time was had by all! Our Chapter has grown over the past 30 years and is still going strong today! Thank you for being part of this influential group of critical care nurses who make a difference in healthcare decisions and patients’ lives! (see story on page 14 and more photos on our Chapter Face Book page) INSIDE THIS ISSUE 1 30th Anniversary celebration 2 Holiday party invitation 2-13 NTI 2015: A Review 13 Future NTI and Horizons dates to remember 14 30th Anniversary event 15-16 Chapter information 17 2015 Scholarship winners 18-19 Endnotes 19-31 Spring 2015 Program Review Our Distinguished group! Front row seated (left to right) - Frances McDonald, Ellen Stokinger, Kathleen Heery, Mary Lavieri 1st row- standing (left to right) - Laura Pruyn, Margaret Chernaik, Christina Cebollero, Susan Sadowski, Sue Ouellette 2nd row (left to right) - Diane Meagher, Michele Woonton, Valerie Fernald, Lisa Bourgeois, Susan Wheeler, Krista DePietro, Linda McGowan, Steve Ouellette Back row (left to right) - Lisa Govoni, Dianne Forsyth, Maureen Ide Not pictured - Doris Barreiro, Mary Nihan, Ellie Dicenso, and Reva Belmore Newsletter 1 It may only be October but you should have already received an invitation to the Chapter Christmas Party on NTI 2015: A Review th. December 13 We are (Be sure to check out photos on our Chapter Face planning to attend the Boston book page!) Pops at the Lowell Memorial Auditorium with dinner By Diane Meagher RN BSN CCRN This year the AACN National Teaching Institute (NTI) & Critical Care Exposition was held May 17-21 in San Diego, California! My husband and I flew out there a few days early the week before to get in a little vacationing. It was not as warm as I expected with temperatures in the 60’s every day. Touring on the hop-on hop-off trolley we learned that the average temperature in San Diego is 70 degrees. They also say it “never” rains in San following at 50 Warren St in Lowell (U-Mass Lowell). RSVP’s were due to Sue Wheeler by Oct 20th. Diego – (“♪it never rains in southern Don’t forget to bring an California♪”). They get ~10 inches of rain per unwrapped toy for our annual Toys for Tots donation too! year, compared to over 40 inches per year in Boston. However, it rained part of each day that my husband was with me in San Diego – but they are having a drought out there and we did not let it interfere with our vacationing! Newsletter 2 (Continued on page 3) (Continued from page 2) We went on a Seal Tour (like a Boston Duck Tour), visited Balboa Park, had pizza in Little Italy, ate (and drank) Mexican in Old Town, had dinner in the Gaslamp Quarter, and toured the USS Midway Aircraft Carrier Museum . Michele and I went back to Balboa Park on Sunday to attend an organ concert at the Spreckels Organ Pavilion - one of the world's largest outdoor pipe organs. Merrimack Valley Chapter (MVC) members Michele Woonton and Rachel Sorrentino joined me in San Diego for NTI. Other MVC members who attended include Ellen Stokinger, Sue & Steve Ouellette, Sue Wheeler, and Colleen Heafey, as well as recent Lowell General Hospital retiree Frances “Twilly” McDonald. Maureen McLaughlin presented at NTI again this year! Natalie Brunetto, who moved to California last year also joined us – it was so great to see her there! And Lowell General Hospital “alumnus” Kathy Laferriere, who also moved out to California this past year, met us for dinner one night while we were there. There may have been other MVC members there, but I did not see them. It’s funny – you seem to run in to the same people again and again, but then never see others. AACN President Teri Lynn Kiss’ theme for this past year was, “Focus the Flame.” At the Monday morning SuperSession she recounted stories that AACN members had shared with her over the past year about how they focused the flame. At the end of the SuperSession everyone received a notepad encouraging them to find ways to refuel their flames every day. The 2015 Visionary Leaders Awards were presented at this SuperSession and one of the three recipients, Dr. Paul Batalden said a few funny and unexpected words, “surround yourself with people you consider friends and stay away from jerks!” The keynote speaker on Monday was Dr. Margaret Hefferman who spoke about “willful blindness” “with anecdotal stories and a startling statistic that 85 percent of employees are afraid to speak up about problems they see within their organization.” “However, we can overcome willful blindness. ‘The health and the survival and the success of our institutions depend not just on the leaders at the top,’ she said. She added that people are the eyes and ears of an organization. ‘It is always the people in an organization who really know what’s going on. And when they dare to look, and they dare to think for themselves, and they dare to speak up, the seven-nation army could never hold them back.’” This willful blindness falls right in line with the “Silence Kills” study and the AACN Healthy Work Environments (HWE) initiative. (Please refer to the links in the endnotes for more information.) The first concurrent session I attended was, “Using Your Bold Voice: The Good, the Bad and the Ugly,” presented by Mary Bylone, RN, MSM, CNML, Regional Vice President of Patient Care Services at William W. Backus Hospital in Norwich, CT. I knew Mary from the AACN Region 1 Horizons committee, and she has also been involved with AACN on a national level. This presentation also fell in line with the HWE initiative, specifically the skilled communication standard. She reviewed the elements of skilled communication and described various ways to effectively use the bold voice of nursing in all conversations around patient care to influence decision-making. She also cautioned about communication in this age of advanced technology and social media and the (cont. . . ) Newsletter 3 (NTI 2015 cont. . . ) potential risks of violating patient privacy and jeopardizing continued employment despite innocent intentions – I know I have heard of nurses being fired for posting inappropriate content on Facebook. This was the first year I attended the Distinguished Research Lecture session. The AACN Distinguished Research Lectureship recognizes significant contributions to acute and critical care nursing research, and the award is sponsored by Philips Healthcare. This year’s recipient was Elizabeth J. Bridges, RN, PhD, CCNS, FCCM, FAAN – she is one of my favorite speakers at NTI. She presented, “Research at the Bedside: It Makes a Difference,” and shared some of her research around the continuum of care of our wounded warriors on their 8,000 mile journey home to the US – the care environment is very different in the back of a cargo aircraft! The last session I attended on Monday was one of my favorites, “Improving Practice Through EBP: Moving Sacred Cows Out to Pasture,” presented by Mary Beth Makic, RN, CNS, PhD, CCRN, CCNS, FAAN, Research Nurse Scientist at the University of Colorado Hospital. Carol Rauen usually co-presents this session but unfortunately was unable to be there due to a family emergency. Mary Beth announced that when they put out feelers for “Sacred Cow” practice habits still in use but not supported by research, they did not receive any new suggestions. So this year she reviewed and gave updates on “Sacred Cows” from the previous seven years. The first topic was Hospital Acquired Conditions: Infection Prevention, CAUTI (Catheter Associated Urinary Tract Infection) and VTE (venous thromboembolism). Principles of infection prevention include isolation of patients, barrier precautions, decontamination of the environment, decontamination of items and equipment, and antibiotic stewardship, but the resounding theme is hand washing. She shared a couple of quotes from Florence Nightingale, “true nursing ignores infection except to prevent it,” and “every nurse ought to be careful to wash her hands frequently during the day…” CAUTI is among the most common HAIs (Healthcare-Associated Infections), but there is an additional risk of patient falls and increased risk of morbidity in older patients. We should all have CAUTI prevention initiatives at our facilities to decrease unnecessary urinary catheter insertions and to promote early removal – nurse driven removal protocols, as well as evidence-based routine care of patients with urinary catheters. Mary Beth shared multiple CAUTI evidence-based resources (see links in endnotes).,,,,,,, All patients should be assessed for risk of VTE. PE (pulmonary embolism) is the most preventable cause of death. Risk factors include bedrest, post-op, immobility, cancer diagnosis, pregnancy, hypercoagulable states, advanced age, extended travel, obesity, and all ICU patients. Prevention is both mechanical and pharmacologic. Intermittent pneumatic compression (IPC) therapy should be fitted properly and in use at all times – remove only to bathe, assess underlying skin, or ambulate. On occasion when I walk into my patient’s room in the morning I find that their IPC has been off all night. Moderate-risk patients should be treated with low dose UFH (unfractionated heparin), LMWH (lowmolecular-weight heparin, e.g., enoxaparin or Lovenox), or fondaparinux (Arixtra). High-risk patients should be treated with LMWH, (cont.) Newsletter 4 fondaparinux, or an oral vitamin K antagonist, e.g., warfarin or Coumadin. Maximize mobility whenever possible.i This appropriately leads in to the next topic – Progressive Mobility, Turning Q2. Complications of immobility affect every body system. Challenges to effective mobility and turning effectiveness include severity of illness, excessive moisture, sheer and friction forces, tissue perfusion and patient weight. Strategies that have been successful over the years include: increased frequency of turning and offloading pressure areas; turn assist devices and turn teams; bariatric beds/surfaces; mobility assessment and progressive mobility programs/standards. Patients should be moved early and often – turning, passive ROM (range of motion), active resistance PT (physical therapy), sitting position, sitting on edge of bed, transfer to chair, and ambulation (marching in place, walking in halls).ii The next topic was Gastric Tube Management and Fecal Incontinence. Verification of gastric tubes in adults is recommended by radiograph. Carbon dioxide readings, aspirate and pH testing may be used to predict tube location during the insertion procedure, but are not sufficient to confirm placement. Mark and document the tube’s exit site from the nose or mouth after radiographic confirmation to monitor for and detect tube dislocation. Listening over the epigastrium for air insufflated through the tube is not reliable in distinguishing between respiratory and gastric placement.iii There is no significant relationship between gastric residual volume (GRV) and aspiration. GRV of 250-500 ml are acceptable. An isolated increased GRV should not lead to holding the tube feeding, but gastric motility should be reassessed for persistent increased GRV. She suggested that avoiding checking GRVs improves nutrition/caloric goals being met. Measures to prevent aspiration include: head of bed (HOB) 30-45 degree angle; use sedation sparingly; frequent assessment (~Q4H) of gastric tube placement; avoid “bolus” tube feedings; monitor ET (endotracheal tube) cuff pressures; oral care; and swallowing evaluation after ET removediv if intubated ≥3 days. Recommendations for managing fecal incontinence include: anticipate incontinence; toileting schedule; good skin hygiene with pH balanced solution; avoid excessive rubbing; apply skin barrier creams; avoid diapers; fecal pouch; fecal containment device – assess rectal tone prior to placement; and pharmacy and dietary consults. She briefly touched on multiple other topics: Normal saline (NS) ET instillation unfortunately continues at the bedside – but is better. I personally find respiratory therapists are more likely to use NS ET instillation than nurses in my practice. Arterial line and cuff blood pressure (BP) measurements should not be compared, but rather accurate measurements, accurate technique, and appropriate trending. BP cuff should be appropriately sized and level with the heart.v Arterial line pressure monitoring system should be assessed for optimal dynamic response (square wave test) and level.vi Fluid resuscitation should be goal directed, albumin is back, synthetic starch (hetastarch, Hespan) is out. Do not routinely strip or milk chest tubes to maintain patency. (cont. . . .) MVC-AACN Newsletter 5 Trendelenberg position provides no demonstrated cardiovascular benefit but poses potential adverse effects, i.e., increased ICP (intracranial pressure), impaired pulmonary gas exchange, and potential for gastric aspiration. However passive leg raising (PLR) at a 45-degree angle with the HOB flat provides a viable alternative. Not all temperature modes are created equal – consider user and device limitations. Here are some tips for using temporal artery thermometers: 1. Place the probe on the center of the forehead, depress the button and keep it depressed. Slide the probe in a straight line across the forehead to the hairline(if you curve down the side of the face, you will miss the temporal artery). 2. Touch the soft depression behind the ear (the "perfume spot"). 3. Remove, read and record temperature.vii It is safe to transfuse blood products through an intravenous (IV) catheter as small as 25 gauge without hemolysis. ICU patients should be allowed blocks of 120 minutes of uninterrupted sleep. Visiting policies should be open, unrestricted, and based on the patient’s preference.viii, ix The patient’s self-report remains the gold standard for pain assessment. Use a validated behavioral pain scale (Behavioral Pain Scale (BPS), Critical Care Pain Observation Tool (CPOT)) for pain assessment for critically ill adult patients who are unable to self-report. Also consider proxy reports of pain by family members.x Please refer to the AACN Practice Alerts cited in the endnotes. What practice “habit” will you change? The keynote speaker at the Tuesday morning SuperSession was Michael Bungay Stanier, author of “Do More Great Work.” “Great work is the work that makes a real difference, has real impact and real meaning for you.” Stanier then encouraged the audience to think about how to remain in a place where great work is possible without stepping foot into what he called the ‘drama triangle.’” He identified three roles in the drama triangle – victim, persecutor and rescuer. He said nurses are rescuers by default. But “rescuers create victims, rescuers create persecutors.” He demonstrated how one person can convert between the 3 roles. He offered some advice to avoid the drama triangle: “First, physically disengage from the situation by walking away and shifting your body into a new position, no matter how silly you feel. Second, ask how you can help, but realize you’re not obligated to say yes to every request. Finally, learn to say no — or at least slow down your rush to say yes.” xi Tuesday afternoon I attended my other favorite session, “Critical Care Studies You Should Know About,” presented by Elizabeth Bridges, PhD, RN, CCNS, FCCM, FAAN, Associate Professor at University of Washington School of Nursing and Clinical Nurse Researcher at the University of Washington Medical Center. Liz shares the principles of research to encourage us to evaluate research for ourselves. She discussed the relative risk or risk ratio (RR) – the risk of an event occurring in the experimental group vs the control group. If the RR is 1, both groups are equal; <1 means less incidence of event in the experimental group; >1 means less incidence of event in the control group. RR is referred to with a 95% confidence interval (CI) – if the 95% CI includes “1,” e.g., 0.88-1.51, then there is no significant MVC-AACN Newsletter 6 difference between the two groups. Liz shared some studies about chlorhexidine (CHG) bathing and HAIs. Overall there is no difference, however, she shared some caveats: the effectiveness may depend on the baseline infection rate; decreases skin colonization – is it a decrease in BSI (bloodstream infection) or a decrease in false positive blood cultures? Where does the CHG reach? VRE carriage primarily perineal, MRSA carriage primarily nares/respiratory; demonstrated effect of CHG on CLABSI (central line-associated BSI); effect of CHG bathing on VAP, CAUTI, CDiff equivocal; CHG may be more effective on gram negative bacteria; and concern re decreased susceptibility to CHG. The next topic was post-ICU posttraumatic stress (PTS). A person with posttraumatic stress disorder (PTSD) has been exposed or a witness to a traumatic event and responded with intense fear, helplessness or horror (DSM IV-R1). Symptoms usually start three months after the event and include reexperiencing phenomena such as intrusive thoughts or recurrent dreams, nightmares, memories; avoidance and numbing – avoiding thoughts, places or situations that serve as reminders of the traumatic event; and increased arousal, e.g., irritability, hypervigilance, easy startling. Symptoms can be assessed using a questionnaire, Impact of Event Scale – Revised (IES-R). Diagnosis requires direct clinical assessment – clinician administered PTSD scale. PTS has become all too common in patients who have survived critical illness – ~1 in 5 ICU patients. Davydow described factors associated with post intensive care PTS including acute stress symptoms during hospitalization and history of major depression and/or prior trauma exposure; benzodiazepines were not an independent risk factor.xii Liz suggested that perhaps the patients who develop PTS are already at risk due to previous psychopathology and/or previous traumatic experience. Parker found a significant association for PTS symptoms with pre-ICU psychopathology, benzodiazepines, and postICU factors, i.e., early post-ICU memories of frightening ICU experiences and post-ICU psychopathology; no association was found with age, sex, corticosteroids, sedation strategy, delirium, severity of illness, admission diagnosis, or mechanical ventilation. ICU diaries decreased PTS symptoms.xiii Ringdal reported that all ICU trauma patients had improved HRQOL (health-related quality of life) at one and five years, but patients with delusional memories had poorer HRQOL.xiv Wade merged factual memories (pain, bleeding, choking) with delusional memories (persecution, religious cults, zombies, aliens, trials and torture) – patients were traumatized with the hallucinations rather than the real events.xv Guttormson found that patients who were minimally arousable had more delusional memories of ICU. Neither higher sedative exposure nor deeper sedation decreased patients’ awareness or memories of facts and frightening experiences.xvi Weinert found more severe PTS symptoms associated with recall of delirious memory during ICU illness but not to factual recall. PTS symptoms were lowest in patients who were most awake or least awake.xvii Long suggested the introduction of psychological support in the ICU for high-risk patients, and the introduction of coping and mindfulness techniques after hospital discharge as PTS prevention strategies, as well as diagnosis, treatment, and psychological support for patient with PTS.xviii Liz recommended an MVC-AACN Newsletter 7 article by Loretta F. Rock about sedation and PTS in Critical Care Nurse.xix The use of an ICU diary has been the subject of some research but there is insufficient evidence for a definitive recommendation. Liz posed many questions: How frequently should notes be completed? Who should write notes (MD, RN, family, others)? How much detail in notes? What to put in – what to leave out? When to give to the patient? How to give to the patient? Who should have access to the diary? What to do with the diary if the patient dies? HIPAA? Next she shared a few studies about sepsis and septic shock: ProCESS (Protocolized Care for Early Septic Shock), ARISE (Australasian Resuscitation in Sepsis Evaluation), and ProMISe (Protocolised Management of Sepsis). Each trial basically challenged the findings of the Rivers Early Goal-Directed Therapy (EGDT) trial back in 2001 that included CVP (central venous pressure) and ScvO2 (central venous oxygen saturation) monitoring, IV fluid resuscitation to a goal CVP of 8 to 12, vasopressor administration to a goal MAP (mean arterial pressure) of ≥65, transfusion of red blood cells to a goal hematocrit of ≥30%, and inotropic agents to a goal ScvO2 ≥70%. ProCESS sought to determine whether the findings of EGDT “were generalizable and whether all aspects of the protocol were necessary.”xx EGDT was compared to a protocol based standard therapy that did not require placement of a central venous catheter, administration of inotropes, or blood transfusions, and a third group randomized to usual care. They found “no significant advantage, with respect to mortality or morbidity, of protocol-based resuscitation over bedside care that was provided according to the treating physician's judgment.” They “also found no significant benefit of the mandated use of central venous catheterization and central hemodynamic monitoring in all patients.” Also of note, antibiotics were administered early prior to enrollment. The ProCESS trial used the Shock Index to guide fluid administration in one of its intervention groups. “The Shock Index has been proposed as a reliable and easy to use tool for the early identification of hypovolemic shock, and the need for intervention, in a number of settings,” although “there are currently no well-designed, prospective studies that validate the use of the Shock Index to guide resuscitative interventions.” The calculation for the shock index is heart rate divided by systolic blood pressure (SBP), and “0.5-0.7 is believed to be a normal shock index. Higher numbers have been shown to be more sensitive than vital signs alone in diagnosing occult shock, need for transfusion and/or operation.”xxi The general idea is that the heart rate should not be higher than the blood pressure. The ARISE trial set out “to test the hypothesis that EGDT, as compared with usual care, would decrease 90-day all-cause mortality among patients presenting to the emergency department with early septic shock in diverse health care settings.”xxii Again, there was no significant difference in mortality between the experimental and control groups. Of note, patients were already volume resuscitated and had been administered their first antibiotic prior to enrollment. Finally, the ProMISe trial also compared EGDT to standard care and also found no significant difference in mortality.xxiii Another noteworthy point – the 60-day mortality for the usual care group in the ProCESS trial was 18.9%, compared to 44.4% MVC-AACN Newsletter 8 in the control group in the Rivers trial. Clearly “usual care” is not what it used to be. Key points include: When patients receive first antibiotics? How long for initial volume resuscitation? Central line – for monitoring vs vasoactive medication administration? When were hemodynamic goals met? The Surviving Sepsis Campaign has just revised their bundles: TO BE COMPLETED WITHIN 3 HOURS: 1) Measure lactate level 2) Obtain blood cultures prior to administration of antibiotics 3) Administer broad spectrum antibiotics 4) Administer 30 ml/kg crystalloid for hypotension or lactate ≥4mmol/L “Time of presentation” is defined as the time of triage in the emergency department or, if presenting from another care venue, from the earliest chart annotation consistent with all elements of severe sepsis or septic shock ascertained through chart review. TO BE COMPLETED WITHIN 6 HOURS: 5) Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arterial pressure (MAP) ≥65 mm Hg 6) In the event of persistent hypotension after initial fluid administration (MAP < 65 mm Hg) or if initial lactate was ≥4 mmol/L, re-assess volume status and tissue perfusion and document findings according to Table 1. 7) Re-measure lactate if initial lactate elevated. TABLE 1 DOCUMENT REASSESSMENT OF VOLUME STATUS AND TISSUE PERFUSION WITH: EITHER: • Repeat focused exam (after initial fluid resuscitation) including vital signs, cardiopulmonary, capillary refill, pulse, and skin findings. OR TWO OF THE FOLLOWING: • Measure CVP • Measure ScvO2 • Bedside cardiovascular ultrasound • Dynamic assessment of fluid responsiveness with passive leg raise or fluid challenge Of note, the 6-hour bundle has been updated; the 3-hour SSC bundle is not affected.xxiv The last topic Liz presented was Thirst in ICU Patients. She shared multiple studies that revealed a 70-90% incidence of thirst.xxv, xxvi, xxvii Samuelson found in ventilated patients, thirst is 1 of 3 most remembered ICU experiences.xxviii Puntillo reported in patients at risk of dying, among 10 symptoms, the patients rate thirst as the most intense and the second most prevalent symptom.xxix Stotts, et al. identified predictors of the presence, intensity and distress of thirst in ICU patients. Thirst presence was predicted by high opioid doses (≥ 50 mg), high furosemide doses (>60 mg), selective serotonin reuptake inhibitors, and low ionized calcium. Thirst intensity was predicted by patients not receiving oral fluid and having a gastrointestinal (GI) diagnosis. Thirst distress was predicted by mechanical ventilation, negative fluid balance, antihypertensive medications, and a GI or "other" diagnosis.xxx Puntillo, et al. tested an oral care intervention bundle for thirst intensity, thirst distress and dry mouth. Inclusion criteria included: oriented to name, ICU >24 hours, RASS -1 to 1 (not sedated/agitated), thirst intensity (TI) (0-10) ≥3, thirst distress (TD) (010) ≥3, and no open oral sores or desquamation. The intervention bundle consisted of oral swab wipes, sterile ice cold water sprays, and a lip moisturizer. “The average decreases in TI and TD scores from MVC-AACN Newsletter 9 pre-procedure to post-procedure were significantly greater in the intervention group vs the usual care group. The usual care group was 1.9 times more likely than the intervention group to report dry mouth for each additional session on Day 1.xxxi Again, Liz posed some questions: Do I need to repeat the intervention 3 times over 15 minutes? Can we give the resources to the patient/family for prn use? How long does the intervention last? Does it work in intubated patients/patients with altered mucosa? How to apply in more deeply sedated patients? How to use in conjunction with oral care to prevent VAE (Ventilator-Associated Events)? As always, Liz creates a culture of inquiry. She ended this topic by stating, “there is no evidence that ice chips help thirst.” Early Wednesday morning I attended a session, “Patient Hand Hygiene: Overlooked Factor in the Spread of Healthcare-Associated Infections,” presented by Kelly Drumright, RN, BSN, CCRN-CMC, CSC, and Jolanda Coffey, RN, BSN, from the Veterans Affairs Tennessee Valley Healthcare System in Nashville, TN. Hand washing is key to preventing HAIs. So the speakers posed the question, “what about the patient’s hands and their hand hygiene? They listed four significant ways patients can transmit pathogens: through the transfer of pathogens in the environment, by direct spread of pathogens to other patients, by crosscontamination through direct contact with HCWs (healthcare workers), and by increasing their own risk of infection from an endogenous source. The CDC (Centers for Disease Control and Prevention) recommends patient hand hygiene: before preparing or eating food; before touching eyes, nose, or mouth; before and after changing wound dressings or bandages; after touching hospital surfaces such as bed rails, bedside tables, doorknobs, remote controls, or the phone; after blowing your nose, coughing, or sneezing; and after using the restroom. Challenges with patient hand hygiene include high acuity level, patient’s physical ability, lack of patient/family education, impeded movement, and perceived importance. They presented research data on hand hygiene compliance among HCWs (doctors, nurses, other staff) as well as patients and visitors. Barker, et al. found that patient hand washing significantly decreased while in the hospital, especially after using the bathroom and prior to eating. However, patients who had better hand-washing practices at home and placed a high value in hand hygiene, tended to have good hand hygiene practices while in the hospital.xxxii The presenters recommended an article that provided a great review of literature and evidence regarding the role of patient hand hygiene in preventing infection, and the authors provide recommendations on developing a patient hand hygiene program.xxxiii The presenters also referred to an article “hot off the press” in the May issue of American Journal of Critical Care.xxxiv Next they shared their own trial at their facility. Finally they shared many hand hygiene resources, including The Joint Commission’s Speak up program, “Five Things You Can Do to Prevent Infections;”xxxv The World Health Organization’s, “Save Lives: Clean Your Hands,”xxxvi and “My 5 Moments for Hand Hygiene for HCWs;”xxxvii and The CDC’s, “Clean Hands Save Lives,”xxxviii as well as others. I personally have considered patient hand hygiene specifically after they clean themselves when using the restroom – but I would most often hand them a bath wipe if there were MVC-AACN Newsletter 10 some leftover in the room. However, they are not antibacterial, so now I have improved my practice by ensuring the presence of a small bottle of hand sanitizer gel that we have available on our supply cart and encouraging the patient to use it. At the Wednesday morning SuperSession AACN President-elect, Karen McQuillan revealed her new theme, “Courageous Care.” She encouraged members to share their stories of Courageous Care with her throughout this next year. The keynote speaker was Allison Massari, a motivational speaker who shared her story of surviving a devastating car accident where she was trapped and burned alive. “Despite being devoured by that excruciating pain, I was shocked to see that the anguish of my loneliness was more potent than the physical agony of burning.” “She went on to tell attendees about Roger Pepper, the stranger who pulled her out of the car and saved her life, the firefighters who discreetly covered her up after the fire stripped her of her clothes and the nurses and medical staff who cared for her so compassionately, and who, over the years, have lifted her up to her calling of spreading love, healing, strength and courage to everyone she meets.” “Sometimes, all it takes is one person to change a life. One moment. One look. You never know the impact you can have on someone else’s life.”xxxix Late Wednesday afternoon a bunch of us attended the session, “Focus the Flame on PAIN: Providing Competent and Compassionate Care to the Patient in Pain,” presented by Maureen McLaughlin, MS, RN, CPAN, CAPA, Clinical Nurse Specialist at Lahey Clinic Hospital and MVC member! Maureen began her presentation with this quote, “pain may be the warning signal that saves the lives of some people but destroys the lives of countless others.”xl She shared some data about pain, prevalence, and financial impact. “Most critically ill patients will likely experience pain sometime during their ICU stay.”xli She shared definitions of pain – the one that resonated with me was, “pain is whatever the experiencing person says it is, existing when he or she says it is.” She described types of pain – nociceptive vs neuropathic; acute vs chronic. She described the neurophysiology of pain. She discussed challenges in the care of the patient with chronic pain, as well as critically ill patients with substance use disorder/longterm opioid use. These complex patients require opiates to sustain their substance use and prevent withdrawal, and they deserve the right to analgesia during an acute illness. Acute on chronic pain management may require a 30% to 100% dose increase to cover the acute pain aspect.xlii Other pain management strategies include trying another opiate, around the clock/continuous dosing, and multimodal. She referred to the adage “prn” is “plan relapse now.” Maureen stressed the importance of accurate medication reconciliation. Although self-report is the gold standard for pain assessment, standardized pain assessment tools (BPS, CPOT) are indicated for patients who cannot self-report. Proxy report by family/caregivers may also provide valuable assessment data. Maureen reviewed a multitude of pain management options including mechanism of action, side effects and special considerations: opioids, neuroaxial or regional analgesics (e.g., epidural, peripheral nerve blocks), NSAIDS (nonsteroidal anti-inflammatory drugs), local anesthetics, NMDA (N-methyl-D-aspartate MVC-AACN Newsletter 11 receptor) antagonists (e.g., ketamine), alphaadrenergic analgesics (e.g., dexmedetomidine), antidepressants/anticonvulsants (e.g., gabapentin, Lyrica), muscle relaxants, adjuvants, nonpharmacological interventions, and multidisciplinary teams. Maureen ended her presentation with this quote, “Pain [is] no longer just a physiologic response awaiting a pharmacologic treatment. Pain [has] become a human response; pain [is] a suffering person in need of both competent treatment and compassionate attention.”xliii Wednesday evening was “Nurses’ Night Off” at the San Diego Zoo. We grabbed a bite to eat before going to the zoo, so by the time we got there it was already getting late and starting to get dark, and the animals were mostly sleeping and/or out of view. But we did get to see the pandas (sleeping), koala beers, a kangaroo, rhinoceros, giraffes, and zebra. Thursday morning I attended a session, “Case Studies in Critical Care as a Result of Information from the Internet,” presented by Ann Lystrup, RN, BSN, CEN, CFRN, CCRN, Clinical Educator at Sutter Physician Services. This was a fascinating session, but most of the case studies were about various types of drug overdoses. The speaker did not provide a handout so I am limited by my memory, but I will share the cases that stand out in my memory – most of which I had never heard of before. First she spoke about vaping (inhaling) alcohol – vaping skips the waiting period to feel the “buzz” because it is absorbed directly into the bloodstream, but the feeling is also shortlived. Evidently some web sites report that it will not be detected on a breathalyzer test, but that is not necessarily true. Another web site points out that you don’t ingest calories, carbs or fillers. There is a higher risk of overdose than with drinking because you don’t know how much alcohol you are ingesting, and inhaled alcohol cannot be purged from the body by vomiting, which is the body’s main protection against alcohol poisoning.xliv Alcohol soaked tampons are another alternative to drinking alcohol. The speaker presented a case study of a young woman who was found unresponsive by her parents, and ultimately a friend spoke up and admitted that the patient had used an alcohol soaked tampon. Again, absorption is direct and there is no way to control the amount of alcohol ingested. She also talked about pruno or prison wine, made from fruit and fermented in plastic bags. She shared a case study of a prisoner who used potatoes because he did not have any fruit, and contracted botulism because of the spores commonly found in soil. The physician made the diagnosis based on symptoms, specifically including drooping eyelids. The final case study that I can remember was a man who had taken some kind of energy supplement, but had taken much more than the recommended dose. He could not sit still and was yelling in the emergency room, mostly unintelligible, but intermittently could be heard to say, “I can’t slow down.” He ultimately died and the speaker said it was like he burned from the inside due to the excessively stimulated metabolism. Sorry about the lack of details with these case studies but my memory is not what it used to be! After NTI was over early Thursday afternoon, Rachel, Michele and I went shopping for souvenirs in the Seaport Village, then went for a late lunch at Seasons 52 where Rachel’s daughter worked as a waitress. Later we took a taxi to Mission Beach, dipped our feet in the Pacific Ocean, and had drinks on a rooftop bar while watching the sunset. We flew home on MVC-AACN Newsletter 12 the red eye that night in time for the Memorial Day holiday weekend because it was my weekend and holiday to work. Upcoming NTI events will be Next year NTI is being held in New Orleans – hope to see you there! held in: (See Endnotes on last page of newsletter) NTI 2016 is in New Orleans! Hope you can make it! 2017 Houston, TX 2018 Boston !!! Our Chapter will be ready to help out again! Horizons 2016 in Warwick, RI Save the dates April 5, 6 & 7, 2016!! Go to www.horizons2016.org for more information! MVC-AACN Newsletter 13 Merrimack Valley AACN Chapter Celebrates 30th Anniversary! Merrimack Valley Chapter members celebrated our 30th anniversary at Lenzi’s on September 17, 2015 with a cocktail reception. Members had a chance to socialize with old and new friends and check out our photo boards with priceless pictures of MVC members and gatherings throughout the years Attendees also received a badge holder with the MVC AACN logo. Linet Americas sponsored our gathering which provided a lovely waitress circulating with delectable treats such as fresh melon and asparagus wrapped in prosciutto, mini rare steak sandwiches with horseradish sauce, and grilled kielbasa with sweet and sour sauce, to name a few. There was also an assorted cheese, cracker, & fruit display with artfully arranged crudités & herb dips. Assorted fancy miniature desserts with coffee and tea (decaf available) were set out near the end of our evening, and judging by the crowd around the table, a big hit! After we all had a chance to socialize, Russell Perkins, the Massachusetts Account Manager for Linet Americas, a hospital bed company, provided an in-service on their ICU bed, the Multicare. Doris Barreiro, Nurse Manager MICU & RRT at Lahey has experience with the bed in her unit and verbalized her satisfaction with helpful features offered on the bed. Next, Sue Wheeler, MVC President for FY 2015 -2016 was pleased to introduce our first MVC President and one of the founding members, Kathy Heery. Kathy worked in the ICU at LGH at the time of MVC’s inception. She has had multiple clinical and management positions in both the private and public sectors as well as leadership roles with national and international companies. Kathy now runs a private practice as an RN Community Care Manager & Organizational consultant. She has published many professional articles and authored 3 books with a fourth coming by the end of his year. I am currently reading her third book, “Too High a Price to Pay: The Health Care Reform Revolution”, and finding that her observations regarding the current health care system are spot on. Kathy reflected on the amazing success of our MVC – initially it was a struggle to recruit enough nurses interested in becoming members for consideration to establish a chapter by AACN National. Kathy related how the interest of critical care nurses in the area to join other chapters in the Northeast in forming the Horizons committee was the driving force behind the formation of our MVC. She closed with a raffle of her book to whomever could name the inaugural year of Horizons (1986), Sue Wheeler was the winner! The MVC BOD presented our Programs Chairperson, Diane Meagher with a framed inspirational quote by Jean Piaget – “The principle goal of education is to create men and women who are capable of doing new things, not simply repeating what other generations have done.” Diane will be stepping down after our Spring 2016 program and we wanted to acknowledge the wonderful job she has done with Programs over the past 15 years. Affordable, quality education and networking opportunities continue to be our main focus as we strive to maintain the vision of AACN – to create a healthcare system driven by the needs of patients and their families where acute and critical care nurses make their optimal contributions. MVC-AACN Newsletter 14 About Our Chapter – Merrimcak Valley AACN In 1985 the Merrimack Valley Chapter started with 20 members. Now, 30 years later, there are almost 90 members and we are growing each year. Please Step Forward with Courageous Care and exercise your ability to show leadership traits. There are opportunities in the chapter to join a committee, attend board meetings, and help set up educational programs and events. Then once you are familiar with the board activities you can, and should, run for an office. Many chapter officers have transitioned from staff to management positions possibly because they have “dared to” “step forward” “with confidence”. P.S. membership dues age 55 years and up are reduced to $59/year; Also if you submit four members for AACN renewal together you can save $10 off each - see forms on AACN website. (www.aacn.org). Also don’t forget to renew your annual Chapter membership (only $10!). Go to the AACN.org website to obtain a MVC application. If you would like to find out about how to become more involved in the Chapter please reach out to any board member. Go to the www.AACN.org website and at the bottom of the page click on “Chapters”. Next click on Massachusetts, Merrimack Valley, and e-mail a chapter officer”, or simply click here: http://www.aacn.org/dm/Chapters/EmailOfficers.aspx?mid=2874 MVC-AACN Newsletter 15 Join Us for the next Chapter Education Class – AACN Class on Critical Care Cornucopia November 3, 3015 7:30am-4:00pm Wyndham Boston in Andover, 123 Old River Rd, Andover, MA See attachment to newsletter e-mail for more details or visit the MVC Chapter page on the AACN.org website 2015-16 Chapter Board Members: Sue Wheeler is the President as of July 2015 Michele Woonton is the Past-President from 2014 Chrissy Cebollero is the President Elect for 2016 and Webmaster Linda McGowan and Doris Barreiro - Scholarship committee Diane Meagher – Programs (until May 2016) Ellen Stokinger – Membership Sue Ouellette – secretary Dianne Forsyth – treasurer Valerie Fernald – publications MVC-AACN Newsletter 16 MVC – AACN 2015 Scholarship Winners Each year our Chapter presents (2) $500 scholarships to high school graduates who are admitted to a nursing program. They submit scholarship applications and the Scholarship committee reviews them and chooses 2 winners each year. The winners for 2015 were Joel Emmott who will be attending the University of Rhode Island and Alison Dunfee who will attend Palm Beach Atlantic University. Joel and his mom were able to join us for dessert at our Transitions dinner at Jules Restaurant in Methuen, but Alison was attending orientation that day and could not attend. Please check out our photos of this evening on our Facebook page! The Scholarship Committee is sending out applications for 2016 scholarships to local high schools. If you have any questions about this process please e-mail our Scholarship Committee (e-mail addresses are on the AACN website on the Chapters page). Be sure to join the Merrimack Valley Chapter AACN page on Face Book! Stay Tuned to the Chapter website, Face Book page and your e-mail for photos and updates from the Chapter on recent and upcoming events! MVC-AACN Newsletter 17 Endnotes from NTI 2015 article i http://www.aacn.org/wd/practice/docs/practicealerts/vte-prevention-practice-alert.pdf?menu=aboutus http://www.aacn.org/wd/practice/docs/tool%20kits/early-progressive-mobility-protocol.pdf iii http://www.aacn.org/wd/practice/docs/practicealerts/verification-feeding-tube-placement.pdf?menu=aboutus iv http://www.aacn.org/wd/practice/docs/practicealerts/prevention-aspiration-practice-alert.pdf?menu=aboutus v http://www.aacn.org/wd/practice/docs/practicealerts/non-invasive-bp-monitoring.pdf?menu=aboutus vi http://www.aacn.org/wd/practice/docs/practicealerts/pap-cvp-measurement.pdf. vii http://www.exergen.com/tathermometry/thermal-images.htm viii http://www.aacn.org/WD/practice/docs/practicealerts/family-visitation-adult-icu-practicealert.pdf ix http://www.aacn.org/wd/practice/docs/practicealerts/family-presence-during-resuscitation-invasive-procedures.pdf x http://www.aacn.org/wd/practice/docs/practicealerts/assessing-pain-critically-ill-adult.pdf xi http://www.ntivoices.com/tuesday-supersession-step-away-from-the-drama-triangle/ xii Davydow DS, Zatzick D, Hough CL, Katon WJ. A longitudinal investigation of posttraumatic stress and depressive symptoms over the course of the year following medical‐ surgical intensive care unit admission. Gen Hosp Psychiatry. 2013;35:226‐ 232 xiii Parker AM, et al. Posttraumatic stress disorder in critical illness survivors: a meta‐ analysis. Crit Care Med. 2015;43(5):1121‐ 1129 xiv Ringdal M et al. Memories and health‐ related quality of life after intensive care: A follow‐ up study. Crit Care Med. 2010;38:38‐ 44 xv Wade DM et al. Intrusive memories of hallucinations and delusions in traumatized intensive care patients: an interview study. Br J Health Psychol. 2014 xvi Guttormson JL. “Releasing a lot of poisons from my mind:” Patient’s delusional memories of intensive care. Heart Lung. 2014;43(5):427‐ 431 xvii Weinert CR, Sprenkle M. Post‐ ICU consequences of patient wakefulness and sedative exposure during mechanical ventilation. Intens Care Med. 2008;34(1):82‐ 90 xviii Long AC, et al. Posttraumatic stress disorder among survivors of critical illness: creation of a conceptual model addressing identification, prevention and management. Intensive Care Med. 2014;40(6):820‐ 829 xix Rock LF. Sedation and its association with posttraumatic stress disorder after intensive care. Crit Care Nurse. 2014;34(1):30‐ 37 xx The ProCESS Investigators. A randomized trial of protocol-based care for early septic shock. N Engl J Med. 2014;370:16831693 xxi http://www.mdcalc.com/shock-index/ xxii The ARISE Investigators and the ANZICS Clinical Trials Group. Goal-directed resuscitation for patients with early septic shock. N Engl J Med. 2014;371:1496-1506 xxiii Mouncey PR, Osborn TM, Power GS, et al. Trial of early, goal-directed resuscitation for septic shock. N Engl J Med. 2015;372:1301-1311 xxiv http://www.survivingsepsis.org/Bundles/Pages/default.aspx xxv Nelson JE, et al. The symptom burden of chronic critical illness. Crit Care Med. 2004;32(7)1527‐ 1534 xxvi Nelson JE, et al. Self‐ reported symptom experience of critically ill cancer patients receiving intensive care. Crit Care Med. 2001;29(2):277‐ 282 xxvii Li DT, Puntillo K. A pilot study on coexisting symptoms in intensive care patients. Appl Nurs Res. 2006;19(4):216‐ 219 xxviii Samuelson KA et al. Stressful experiences in relation to depth of sedation in mechanically ventilated patients. Nurs Crit Care. 2007;12(2):93‐ 104 xxix Puntillo KA, et al. Symptoms experienced by intensive care unit patients at high risk of dying. Crit Care Med. 2010;38(11): 2155‐ 2160 xxx Stotts NA, Arai SR, Cooper BA, et al. Predictors of thirst in intensive care unit patients. J Pain Symptom Manage. 2015;49(3):530-538 xxxi Puntillo K, et al. A randomized clinical trial of an intervention to relieve thirst and dry mouth in intensive care unit patients. Intensive Care Med. 2014;40(9):1295‐ 1302 xxxii Barker A, Sethi A, Shulkin E, et al. Patient hand hygiene at home predicts their hand hygiene practices in the hospital . Infect Control Hosp Epidemiol. 2014;35(5):585-588 xxxiii Landers T, Abusalem S, Coty M-B, & Bingham J. Patient-centered hand hygiene: the next step in infection prevention. Am J Infect Control. 2012;40:S11-S17 xxxiv Fox C, Wavra T, Drake DA, et al. Use of a patient hand hygiene protocol to reduce hospital-acquired infections and improve nurses’ hand washing. Am J Crit Care. 2015;24(3):216-224 xxxv http://www.jointcommission.org/assets/1/18/Infection_Control_Brochure.pdf ii MVC-AACN Newsletter 18 xxxvi http://www.who.int/gpsc/5may/en/ http://www.who.int/gpsc/5may/Hand_Hygiene_When_and_How_Leaflet.pdf?ua=1 xxxviii http://www.cdc.gov/handwashing/ xxxix http://www.ntivoices.com/the-essence-of-courageous-care xl As cited in Church, E.J. What imaging teaches us. Radiologic Technology. 2013;84(4):349-372 xli Barr, J. et al. Clinical practice guidelines for management of pain, agitation, and delirium in adult patients in ICU. CCM. 2013;41(1):263-306 xlii Drew D. & St. Marie B. (2011). AACN Adv Crit Care. 2011;22(3):238-254 xliii Pasero C & McCaffery M. Pain Assessment and Pharmacological Management. 2011. St. Louis, MO: Mosby; page vii xliv http://en.wikipedia.org/wiki/Alcohol_inhalation xxxvii Also for your reading enjoyment and education please read this program review. 2015 Spring Program Review – “Getting to the Heart of the Matter” By Diane Meagher RN, BSN, CCRN On April 14, 2015 we held our spring program, “Getting to the ‘Heart’ of the Matter,” which included a variety of cardiac topics. Over 100 participants attended so we were “bursting from the seams” of the Concord Amphitheater! The first speaker was Kathleen Schultz, RN, BSN, BC, a Staff Nurse and ECMO Educator in the Cardiac Surgical ICU at Massachusetts General Hospital. Kathleen began the day with, “Back to the Basics: A Review of the Cardiac System.” She started with a review of basic cardiac anatomy, including valvular structures, coronary arteries, muscle and electrical conduction. Kathleen introduced a mnemonic to describe the determinants of cardiac output: Contractility – amount of ‘stretch,’ or force of the cardiac muscle Rate – frequency of blood ejected from the heart Afterload – pressure the left ventricle generates to contract Preload – volume of blood in left ventricle prior to contraction Cardiac output (CO) = HR (heart rate) x SV (stroke volume). Decreased CO translates to decreased perfusion to all organs: lungs – congestion leads to pulmonary edema, decreased oxygenation, shortness of breath; liver – congestion leads to peripheral edema; kidneys – decreased excretion of water. Ejection fraction (EF) is the percentage of blood ejected from the left ventricle during systole. Normal is 55-70%, 4050% is mildly reduced, 30-40% is moderately reduced, 20-30% is moderately severe reduction, and <20% is severely reduced. MVC-AACN Newsletter 19 Next she described the pathophysiology of heart failure. Systolic dysfunction is associated with loss of contractility – ineffective squeezing of the ventricles can be due to impaired contractility, e.g., myocardial infarction (MI); increased afterload, e.g., hypertension (HTN); cardiomyopathy and valvular disease. Diastolic dysfunction is associated with impaired ventricular filling and decreased stroke volume, and may be due to left ventricular hypertrophy, hypertrophic cardiomyopathy, aortic stenosis, and chronic HTN. She further described the pathophysiology of cardiomyopathy. Dilated cardiomyopathy is associated with an enlarged left ventricle and systolic dysfunction with diminished contractility resulting in decreased EF, increased end-diastolic volume, decreased ventricular SV, and biventricular failure, and may be due to ischemia, mechanical (valve disease, HTN), viral (coxsackie, CMV, HIV, etc.), peripartum, and toxic (alcohol). Hypertrophic cardiomyopathy is usually a genetic disorder associated with a thickened left ventricle, impaired diastolic function and decreased ventricular compliance – thickening of the septal wall causes obstruction to the left ventricular outflow tract. In restrictive cardiomyopathy, the walls of the ventricles become stiff, but not necessarily thickened – the myocardium becomes rigid and noncompliant, ventricular filling is impeded, and filling pressures are increased during diastole, resulting in right heart failure, systemic venous congestion, cardiomegaly and dysrhythmias. Causes of restrictive cardiomyopathy include scleroderma, lymphoma, and amyloidosis. Signs and symptoms of right-sided heart failure include fatigue, distended jugular veins, ascites, enlarged liver and spleen, anorexia and complaints of gastrointestinal distress, weight gain and dependent edema. Signs and symptoms of left-sided heart failure include pulmonary congestion (cough, crackles, wheezes, blood-tinged sputum, tachypnea), restlessness, confusion, orthopnea, exertional dyspnea, paroxysmal nocturnal dyspnea, tachycardia, fatigue and cyanosis. Cardiogenic shock is systemic hypoperfusion (oliguria, cold extremities, confusion) in the setting of severely depressed cardiac output (cardiac index <1.8 x m2/min) and sustained systolic arterial hypotension (systolic arterial pressure <80 mmHg) with elevated filling pressures (pulmonary capillary wedge pressure >18 mmHg). Cardiogenic shock is predominantly due to left ventricular (LV) failure, but can be due to right ventricular (RV) shock, ventricular septal rupture, and tamponade; MI with LV failure is the most common cause. She reviewed the New York Heart Association (NYHA) Functional Classification for heart failure: I no symptoms II symptoms with moderate-marked activity III symptoms with mild activity IV symptoms at rest She described the stages in the development of heart failure. Patients with stage A heart failure are at high risk for heart failure but do not have structural heart disease or symptoms of heart failure – this includes MVC-AACN Newsletter 20 patients with HTN, diabetes, coronary artery disease, previous exposure to cardiotoxic drugs, or a family history of cardiomyopathy. Patients with stage B heart failure have structural heart disease but have no symptoms of heart failure – this includes patients with left ventricular hypertrophy, previous MI, LV systolic dysfunction, or valvular heart disease, all of whom would be considered to have NYHA class I symptoms. Patients with stage C heart failure have known structural heart disease and current or previous symptoms of heart failure. Their symptoms may be classified as NYHA class I, II, III, or IV. Patients with stage D heart failure have refractory symptoms of heart failure at rest despite maximal medical therapy, are hospitalized, and require specialized interventions or hospice care. All such patients would be considered to have NYHA class IV symptoms. Then she presented recommended therapy by stage. Primary interventions for the treatment of heart failure begin with lifestyle changes: diet – low salt, alcohol free; weight loss; physical activity; and smoking cessation. Oral medications include: ACE (angiotensin-converting-enzyme) inhibitors – lower BP, block neurohormones, inhibit remodeling; beta blockers – slow HR, lower BP, decrease stress hormones; digoxin – slows HR, improves EF; ARBs (angiotensin II receptor blockers) – lower BP; diuretics – remove excess fluid; nitrates – vasodilators, reduce preload. Critical care interventions include IV therapy: diuretics; inotropes – milrinone, dobutamine, dopamine; vasodilators – nitroglycerin, nitroprusside, and nesiritide. Other critical care interventions include: Swan-Ganz catheter – measures filling pressures; intra-aortic balloon pump (IABP) – unloads LV; Ventricular Assist Device (VAD) – provides resting of ventricles; Extracorporeal Membrane Oxygenation (ECMO) – provides resting of ventricles and/or lungs; transplant/artificial heart; palliative care. Invasive interventions include: electrophysiology lab – biventricular pacing, ICD (implantable cardioverter defibrillator); catheterization lab – angioplasty, stents, TAVR (transcatheter aortic valve replacement), MitraClip; cardiac surgery – CABG (coronary artery bypass graft), valve replacement, septal myomectomy. Copyright © American Heart Association, Inc. All rights reserved. MVC-AACN Newsletter 21 Kathleen’s next presentation was, “ECLS Explained: Adult ExtraCorporeal Life Support for Bedside Nurses.” She began with a little history – the first successful use of adult ECMO was in 1972. ECMO is a heart and/or lung support – similar to bypass used during cardiac surgery. Candidates for ECMO are patients with severe respiratory and/or cardiac failure who are thought to benefit from support, and when all other options have been exhausted. Inclusion criteria for VV (venovenous) ECMO include: acute hypoxic or hypercarbic respiratory failure – sat 88% on FiO2 100%, respiratory acidosis with pH <7.20; normal RV/LV function; minimal vasopressor/inotrope support. Inclusion criteria for VA (venoarterial) ECMO include: cardiogenic shock with end-organ hypoperfusion – CI <2.2 or SvO2 <60% on two inotropes, high biventricular pressures with PCW >20, CVP >15, worsening metabolic acidosis, hypotension with significant vasopressor requirement; unstable arrhythmias. Absolute contraindications to ECMO include: unrecoverable cardiac or respiratory function and not a candidate for transplant or VAD, neurologic catastrophe, mechanical ventilation >7 days, CPR >60 minutes in-house (otherwise CPR >30 minutes), severe aortic insufficiency, acute aortic dissection, end-stage liver disease, BMI >40, contraindication to anticoagulation or refusal to receive blood products. Relative contraindications to ECMO include: age >70, active cancer, suicide attempt, chronic kidney disease, multi-organ system failure 3 organs, significant PVD. VV ECMO is respiratory support. Blood is drained from the venous system, oxygenated and ventilated, then returned to the central venous circulation – removes CO2 and provides fully saturated blood to the return vessel. VV ECMO provides no direct hemodynamic support, but increased oxygen delivery to the coronary and pulmonary circulation can improve cardiac output. VV ECMO cannulation is typically peripheral (right femoral vein and left femoral vein). Blood flows back into the patient at the level of the right side of the heart, then through the patient’s native lungs. RA-PA central cannulation is used in the setting of oxygenation requirement and RV failure, e.g., severe pulmonary HTN. VV ECMO flow is low (2-4 L/min) so expect a lower SaO2 with VV ECMO due to ECMO blood mixing with native blood – 85% is okay. The goal is oxygen delivery, so monitor hemoglobin levels closely and maintain hematocrit >30. Hemodynamic stability should be maintained by volume, but also inotropes, vasopressors and vasodilators as needed. If IABP is required, may change to VA ECMO. Intubation or tracheostomy is only necessary for secretion control. Apnea is okay on VV support as ventilation and respiration come from the ECMO circuit. Anxiolytics may be better for controlling tachypnea on an awake patient. Mobility, i.e., ambulation, is important to prevent deconditioning and improve activity tolerance, as well as decrease complications of mechanical ventilation. VA ECMO provides cardiac and respiratory support – provides hemodynamic support and O2/CO2 exchange. Blood is pulled from the venous system and returned to the arterial system. VA ECMO is indicated for: post-bypass (cardiotomy) support – failure to wean from bypass after surgery; post cardiac transplant – usually due to primary graft failure; and other condition that lead to severe cardiac failure – cardiomyopathy, cardiogenic shock s/p MI, pulmonary embolism, sepsis, overdose, and profound hypothermia. Typical cannulation sites for VA ECMO are either peripheral – right femoral vein and left femoral artery, or central – RA and aorta. VA ECMO provides full cardiac support (usually ~80%). Blood flow is 4-6 L/min – adequate MAP 50-70 mmHg, adequate SvO2 >70%, and SpO2 >95% if obtainable. VA ECMO is preload and afterload sensitive – provide hemodynamic support with volume, vasopressors, vasodilators and inotropes as needed. VA ECMO is partial bypass – some ‘native’ blood still goes through the native lungs, then to the native LV, and then native blood is ejected from the LV into the aorta. The aorta feeds the innominate artery, which feeds the head, neck and right arm – cerebral hypoxia is the perfusion of the ‘native ‘blood into the MVC-AACN Newsletter 22 body. Cerebral hypoxia occurs only when the femoral artery is cannulated on VA ECMO when pulsatility is present. The right radial artery reflects the upper part of the body, which is perfused by blood that goes through the native lung and comes out of the LV. The left radial artery reflects the lower part of the body, which is perfused by blood that comes out of the femoral artery cannula. Thus, arterial blood gases are checked from both sites. Non-pulsatile flow occurs on full support – no flow through the pulmonary circulation or the left side of the heart – increases the risks of left heart distension, pulmonary or left heart thrombosis and coronary ischemia. SpO2 may not be obtained on non-pulsatile flow. Pulsatile flow occurs on partial support – some pulmonary flow is maintained – reduces the risks of left heart distension and thrombosis. Kathleen summarized some key points: Preload is indirectly proportional to ECMO flow – as flow increases, preload decreases. Afterload is directly proportional to ECMO flow – as flow increases, afterload increases. Cerebral hypoxia is not present in VV ECMO. CO from a Swan-Ganz catheter is not accurate on VA ECMO since the majority of the circulating blood volume is bypassing the pulmonary circulation. ECMO does not fix the problem, it just support patients to give them time to recover. Next she reviewed the management of the patient on ECMO. Patient management goals include: optimize blood pressure, perfusion and acid-base balance – hct, vasopressors, volume (fluids, plts, FFP, blood if indicated), bicarbonate/sweep flow; evaluate and correct any electrolyte abnormalities; evaluate and correct any coagulopathy – check CBC, plts, PT, PTT, fibrinogen. The ventilator is usually managed at low settings to allow the lungs to rest – low rate (8-10/min), long inspiratory time, low PIP (20-25 cmH2O), low FiO2 (<30%), low PEEP (~10 cmH2O). Endotracheal tube (ETT) suctioning should be gentle and slow, just the length of the ETT to avoid bleeding. Bronchoscopes are performed as needed. Patients should be turned every two hours or via bed rotation therapy – open chest precautions with RA-PA cannulation. ECMO patients may need a lot of sedation during the first 12-24 hours. Propofol and fentanyl are first choice medications. The goal of sedation and pain management is to avoid spontaneous breathing, minimize the metabolic rate and patient movement, and maximize patient comfort. Patients should have daily sedation holidays to allow for neurological examination, then resume sedation and narcotics – optimize, don’t maximize. These patients are at high risk for skin breakdown, so diligent skin care is indicated – turn at least every 2 hours, dry linens, barrier protection ointment as needed, fecal containment bags if indicated. ECMO patients are at high risk for infection and require sterile cannula dressing changes daily and as needed, and diligent line care (IV, central lines, chest tubes). Prophylaxis antibiotics are indicated for open chest cannulation and peripheral cannulation, and patients should be pan-cultured for fevers 38C. Renal compromise is another management issue – urine output will initially be low or none. As renal blood flow increases, urine output will increase. Edema should be controlled with diuretics and hemofiltration – early CVVH (Continuous Veno-Venous Hemofiltration) if indicated – can be run through the ECMO circuit. The goal is the patient’s “dry” weight. Finally, nutrition should be initiated within 24 hours of implant – consult re tube feeds or TPN. ECMO patients require full caloric and protein support. Blood glucose should be monitored and continuous insulin infusion if indicated – lowers the risk of infection. A bowel regimen should also be employed. MVC-AACN Newsletter 23 Next she discussed ECMO weaning and decannulation. She listed indications of readiness to wean. With VA ECMO – BP increases, pulsatility returns or improves on arterial line tracing, right radial arterial line pO2 decreases (more blood is going through the native heart, this blood is typically less oxygenated), and CVP and PA pressures increase. ECMO support is typically turned down to assess native function. With VV ECMO – gas exchange can usually be maintained on low FiO2, native lungs are able to maintain ventilation when the sweep rate is minimal (<2 lpm). ECMO support does not need to be changed to assess native function. The team evaluates if the patient can adequately support him/herself – adequate ACT/PTT, initiation/increase of cardiac infusions, increase ventilator settings; recovery of function (heart and/or lungs): VA – BP, echocardiogram, ABG; VV – ABG. VA percutaneously inserted cannulas are removed, and direct pressure should be maintained for a minimum of 30 minutes. If bleeding continues after decannulation, direct pressure must be maintained for another 20 minutes. Direct cut down access should be removed in the OR due to the need to repair the femoral artery. The patient should remain flat for six hours after decannulation. Central cannulation is removed in the OR. VV percutaneously inserted cannulas are simply pulled, and then a purse string suture is placed at the skin. Direct cut down access must be explored, and a purse string suture can be placed on the femoral vein. Venous pressure will not create a hematoma. Observe the site for bleeding, especially if the patient is coughing or straining. RA-PA is decannulated in the OR. Be prepared for complications during decannulation – 2 nurses, blood cooler in room with 4 units each PRBC and FFP, protamine, FiO2 at 100%, normal saline for volume, and open chest tray accessible. Postdecannulation therapy is optimized and weaned as indicated – inotropes, vasopressors, vasodilators, IABP, mechanical ventilation. Potential emergencies include bleeding, anticoagulation, hemodynamics, air in the circuit, accidental decannulation, and lethal arrhythmias/CPR. Anticoagulation is generally required with ECMO – it is necessary to balance the risk of clotting with the risk of bleeding. It is okay to hold anticoagulation if the patient is bleeding. Bleeding complications occur in approximately 50% of patients. Transfusion thresholds: Hgb >8.5 – >10 if SvO2 is low; Plts >20,000 - >80,000 if bleeding; INR <2.5 - <1.6 if bleeding; fibrinogen >150. Finally, she reviewed troubleshooting with ECMO – generally gradual declines are a patient related issue, sudden declines are a circuit related issue. For example, a sudden drop in SaO2 in VA ECMO is always a mechanical issue, i.e., empty oxygen tanks, oxygenator function. Sudden/accidental decannulation is extremely dangerous – the patient who is on complete ECMO support will become unstable very quickly and is at extremely high risk for cardiac arrest. Immediate interventions include holding pressure on the decannulated site, clamping the other cannula, and maximizing IV pressors. Lethal arrhythmias are treated per ACLS protocol with VV ECMO – chest compressions are typically indicated except with central cannulation. Lethal arrhythmias are less concerning with VA ECMO – attempt chemical code first – chest compressions are not indicated. After the morning break, Marcia Bixby RN, MS, CS, CCRN presented, “Cardiac Cath Lab Procedures.” Marcia is a Critical Care Clinical Nurse Specialist who has extensive critical care experience including consulting for education programs, and she presented on Intra-abdominal hypertension at our GI program 5 years ago. Marcia identified patients who are appropriate for cath lab procedures: patients whose symptoms/disease are not readily identified by non-invasive methods; patients with chest pain/STEMI (ST segment elevation MI) who need immediate diagnosis and treatment; patients who have progression of a MVC-AACN Newsletter 24 new or known disease that need accurate information to manage medical therapies; patients who do not respond as expected to medical management for hypertension, angina, unstable angina; patients with pulmonary disorders, e.g., pulmonary hypertension; PFO (patent foramen ovale), ASD (atrial septal defect), VSD (ventricular septal defect); valve disease – aortic and mitral; and cardiomyopathy – LVH (left ventricular hypertrophy). Next Marcia discussed non-invasive cardiac diagnostic procedures. EKG (electrocardiogram) is used to identify old or new ischemic changes, old/missed MI, and irregular rhythms. 2-dimensional echocardiogram (TTE – transthoracic echocardiogram) identifies heart structures, estimates pressures and ejection fraction, identifies abnormal wall motion, clot or abscess formation, valve disease – aortic, mitral, pulmonic. 3-dimensional echocardiogram (TEE – transesophageal echocardiogram) requires sedation/analgesia and provides pressures, ejection fraction, valvular function and wall motion. Cardiac CT (computed tomography) can be used to identify plaque, calcium, aneurysm, and pulmonary embolus (PE). Cardiac MRI (magnetic resonance imaging) provides still or moving images of cardiac function, valve movement with systole/diastole, wall motion, and ejection fraction. Stress testing monitors the patient while exercising – heart rate, blood pressure, EKG ST depressions/elevations, chest pain or shortness of breath. Bruce protocol is a standardized method of treadmill exercise testing with stages of incline in 3 minutes increments. Modified Bruce protocol uses slower/lower incline. Medications may be used for stress testing in patients unable to exercise on the treadmill. Nuclear imaging utilizes radioactive dye to reveal myocardial muscle perfusion – resting and stressed images. When non-invasive testing is not helpful with the diagnosis, or when findings are not consistent with the patient’s complaints/symptoms, cardiac catheterization is indicated. Marcia started the “when to go to cath lab” portion of her presentation with, “why not go to cath lab?” and listed potential risks and complications: venous or arterial access – vessel rupture or dissection, compromise distal perfusion, arrhythmias or hemodynamic upset, contrast, anticoagulation, moderate sedation, stroke, MI or death, radiation exposure/burn. Then she went on to discuss various cath lab procedures. RHC (right heart catheterization) requires venous access, evaluates hemodynamics, forward flow, pulmonary HTN, pulmonary artery occlusive pressure, right or left heart failure, measures oxygen saturations, and can be done with exercise-stress test. LHC (left heart catheterization) requires arterial access and injects contrast to coronary vessels to identify lesions/obstructions – RCA (right coronary artery) is associated with inferior EKG lead changes; LCA (left coronary artery) – left main coronary artery spits to LAD (left anterior descending – associated with anterior EKG lead changes) and circumflex – associated with posterior EKG lead changes. A pressure wire can evaluate obstruction to flow. LHC procedures include thrombectomy, angioplasty, stents, rotoblator – calcium lesions, valve/vessel gradients. Defects, i.e., PFO, ASD, and VSD can be closed in the cath lab. Mechanical support, e.g., IABP, LVAD (left ventricular assist device), RVAD (right ventricular assist device), and ECMO can be placed in the cath lab. Finally, valve repair – balloon valvuloplasty, TAVR, Mitral Clip can be performed in the cath lab. In summary, cath lab procedures can identify vascular and structural abnormalities that are not clearly identified by non-invasive workup, accurately measure blood flow to arteries, accurately measure pressures, and diagnose structural anomalies, as well as perform minimally invasive procedures without surgical intervention for patients who are/may not be surgical candidates. Marcia ended this session with a reminder of the risks and potential complications: venous or arterial access – vessel rupture or dissection – MVC-AACN Newsletter 25 EMERGENT; compromise distal perfusion – LOSS OF LIMB; arrhythmias/hemodynamic upset – PRESSORS; contrast – CIN (contrast induced nephropathy); anticoagulation – BLEEDING, RETROPERITONEAL BLEED; moderate sedation – RESPIRATORY/HEMODYNAMIC; MI or death – “nothing is without risk!!!!!!!” After lunch David Abate, the Northeast Region Senior Clinical Consultant for Thoratec Corporation presented, “VADs – Ventricular Assist Devices.” David began with some statistics about the prevalence of heart failure, advanced heart failure, and mortality. He compared the number of heart donations each year, approximately 2200, vs 300,000 Class IV heart failure patients – although not everyone who is in Class IV heart failure is a candidate for transplant. A VAD is a mechanical device that circulates blood throughout the body when the heart is too weak to pump blood on its own. He went on to discuss the history and progression of VADs. In 1982 Thoratec manufactured the first implanted Paracorporeal Ventricular Assist Device (PVAD), and the first successful bridge-to-transplant was in 1984. Thoratec’s next generation VAD is the HeartMate IIÒ Left Ventricular Assist System (LVAS). The HeartMate II is indicated for inpatient and outpatient use in bridge-totransplantation and destination therapy. For patients waiting for a heart transplant, a VAD may help them survive until a donor heart is available. Bridge-to-transplant (BTT) criteria include non-reversible left heart failure, imminent risk of death, and candidate for cardiac transplantation. Some advanced heart failure patients may not be candidates for a transplant because of other comorbidities or age – these patients may benefit from long-term VAD support, called Destination Therapy. Destination Therapy (DT) criteria include NYHA Class IIIB or IV heart failure, optimal medical therapy 45 of last 60 days, and not a candidate for cardiac transplantation. David described the components and function of the device but that is beyond the scope of this article. He did have some samples of each device to pass around the room and there was quite a difference in the size and weight between the first and second generation. Patient selection considerations include: no trial data on BSA <1.3 m2, limited data on pediatric patients (age <18 years), ability to tolerate/allergy toward anticoagulation, social support, acceptance of blood products, pregnancy, and nonreversible end organ failure. Device troubleshooting is also beyond the scope of this article, but he did share some real life operator errors – forgetting to have extra power with them at all times, showering without the shower kit, and trauma to the percutaneous lead, e.g., hit with a hammer, slammed in car door, and caught on a shopping cart. Next he discussed Thoratec’s CentriMag Extracorporeal Blood Pump. CentriMag is indicated to pump blood through the extracorporeal bypass circuit for extracorporeal circulatory support for periods appropriate to cardiopulmonary bypass (up to 6 hours). It is also approved as a RVAD to provide temporary circulatory support for up to 30 days for patients in cardiogenic shock due to acute RV failure – intended for use in an ECMO circuit to provide cardiopulmonary support for up to 30 days when used with other commercially available components approved for this application. Early recognition and early intervention are key in patient selection for this device. CentriMag will not reverse late stage damage to organs caused by periods of hypotension/hypoperfusion secondary to cardiac failure. David ended his presentation with a hint about HeartMate III LVAS, which is currently in clinical trials. After the afternoon break the next presentation was, ‘Transcatheter Valve Therapies,” by Kimberly Guibone ACNP, Structural Heart Coordinator at Beth Israel Deaconess Medical Center in Boston, MA. Aortic stenosis (AS) is the most prevalent native valve disease. Causes of AS include rheumatic valve disease, bicuspid aortic valve (the aortic valve is normally tricuspid), and calcific/degenerative aortic valve disease. Kim shared a mnemonic to describe the symptoms of AS: MVC-AACN Newsletter 26 Syncope, dizziness Exertional angina Exertional dyspnea, shortness of breath, decreased exercise tolerance. Medical therapy is to treat symptoms and manage CHF (congestive heart failure) – beta-blockers, diuretics, and ACE inhibitors. Surgical aortic valve replacement (AVR) involves median sternotomy, open pericardium, cardiopulmonary bypass machine, diseased valve cut out, replacement valve sewn in, and carries a mortality risk of 1-3%. Balloon aortic valvuloplasty improves the stenotic valve by placing a balloon catheter inside the valve and inflating the balloon – this is a temporizing, palliative measure. TAVR (transcatheter aortic valve replacement) is a minimally invasive approach to implanting an artificial heart valve inside a stenotic aortic valve via catheter for those patients at high or extreme risk for surgical aortic valve replacement. Patient selection criteria include: severe AS – AVA (aortic valve area) <0.8-1.0, mean gradient >40mmHg, peak velocity >4.0, symptoms of NYHC II or greater, and determined to be of high or extreme risk for surgical AVR by 2 cardiac surgeons. Echocardiogram regularly establishes the diagnosis – left ventricular function, extent of hypertrophy, amount of valve calcification, transvalvular pressure gradient, and aortic valve area. STS (Society of Thoracic Surgeons) Risk Calculator is used to determine risk – a predicted mortality risk based on 30 clerical and demographic inputs. STS risk score of >10% is considered high risk whereas STS risk score of >15% is considered extreme risk. Some limitations include bleeding disorders, hostile chest (“any of the following or other reasons that make redo operation through sternotomy or right anterior thoracotomy prohibitively hazardous: abnormal chest wall anatomy due to severe kyphoscoliosis or other skeletal abnormalities (including thoracoplasty, Potts' disease), complications from prior surgery, evidence of severe radiation damage (e.g. skin burns, bone destruction, muscle loss, lung fibrosis, or esophageal stricture), history of multiple recurrent pleural effusions causing internal adhesions)[i] and calcified aorta. Another consideration is frailty – a multisystem dysregulation leading to decreased physiologic reserve and increased vulnerability to stressors. The Cardiovascular Health Study (CHS) index definition is when 3 or more of the following five criteria are met: 1. Weight loss (>5% in the last year) 2. Exhaustion 3. Weakness (decreased grip strength) 4. Slow walking (>6-7 seconds for 15 feet) 5. Decreased physical activity (males <383 kcals, females <270 kcals) Kim introduced two devices: Sapien XT Transcatheter Valve and CoreValve. Access routes include transfemoral, subclavian, direct aortic and transapical. The procedure involves the structural heart team: interventional cardiologist, cardiac surgeon, anesthesiologist (general anesthesia), perfusionist, OR team, and cath lab team; hybrid operating room, and procedure time of 2 to 4 hours. Post-operative transfemoral cases go to the CCU, direct aortic/transapical/thoracotomy cases go to CVICU. Patients are placed on dual MVC-AACN Newsletter 27 antiplatelet therapy with aspirin and clopidogrel for > 3 months. Early extubation and mobilization are key. Sapien recipients advance to the floor on POD#1, CoreValve recipients advance to the floor on POD#2. Hospital length of stay is 4-7 days. Potential complications include neurological event/CVA, arrhythmias/AV block, vascular access complications and CHF. Mitral regurgitation (MR) is the most common type of heart valve insufficiency. Types of mitral regurgitation include degenerative MR caused by mitral valve prolapse or by flail leaflet, and functional MR. Symptoms include dyspnea, lethargy, fluid retention and arrhythmias/atrial fibrillation. Echocardiogram can demonstrate the degree of MR: mild <20%, moderate 20-40%, moderate to severe 40-60%, and severe >60% with >0.4 cm2 regurgitant orifice area. Treatment options include medical therapy, surgery and percutaneous repair. Medical therapy includes afterload reducing agents, diuretics, calcium channel blockers, betablockers, rate controlling agents, and anticoagulation (for atrial fibrillation). Surgical options include repair and annuloplasty, and mitral valve replacement. Transcatheter mitral valve repair (TMVR) is a percutaneous option – percutaneous leaflet plication (edge-to-edge leaflet repair) for patients at high or extreme risk for surgery. Kim introduced the MitraClip device for this procedure. Kim went on to describe Heart Valve Centers of Excellence according to the AHA/ACC Guidelines. She was very pleased and proud to announce that Beth Israel Deaconess Medical Center implanted the first commercial CoreValve in the United States in January 2014! She also shared several current ongoing trials of transcatheter valves: CoreValve Surtavi Intermediate Risk Trial, Lotus Valve – REPRISE I Trial, and CoreValve Evolut Trial. The final presentation of the day was, “Cardiac Transplantation,” by John Whitlock RN, MS, Clinical Nurse Specialist for Cardiothoracic Surgery and Invasive Cardiology at Beth Israel Deaconess Medical Center in Boston, MA. John began by describing the evaluation process for transplant. Patients must meet certain criteria regarding heart failure: a history of repeated hospitalizations for heart failure; need for VAD or artificial heart to support circulation; increasing types, dosages, and complexity of medications; and a reproducible VO2 (oxygen consumption) <14 ml/kg/minute. Patients may be evaluated early and placed at the bottom of the list – this avoids last minute decision-making, testing, etc. Patients must also meet certain general criteria: age up to 70; BMI >21 kg/m2 and <40 kg/m2; and social – aptitude, supports, financial needs. Patients may be taken off the list and placed back on – this can happen multiple times for some patients. Transplant evaluation includes patient interviews with a cardiologist, cardiac surgeon, transplant coordinator, social worker, psychiatrist and dietician. Testing includes pulmonary function tests – strength, capacity, oxygenation; myocardial VO2 – exercise tolerance; RHC – pulmonary blood flow/pressures, O2 samples; and echocardiogram – structural anomalies (tumor, aneurysm, etc.). Other testing includes EKG; CXR (tumors, etc.); blood work – basics: CBC, PLT, coagulation studies; organ specific; infectious disease (HIV, hepatitis, etc.) – antirejection drugs lower immunity thresholds; oncological – r/o subclinical process. The Transplant Selection Committee includes the disciplines mentioned previously as well as bedside nursing, financial coordinator, and consult services (ID, renal, etc.). Nursing interventions for transplant evaluation include teaching, accurate information, and emotional support – this is a big decision! What are the family dynamics? What is the patient’s coping history? How can you help the patient be successful? If a patient is determined to be an appropriate candidate, the following information is also entered into the United Network of Organ Sharing (UNOS): blood type, body size (small body = small heart), severity of illness (list placement), and location – distance can play a vital role – heart ex-situ 4 to 6 hours. MVC-AACN Newsletter 28 · · · · · · · · John went on to describe the transplant list status: Status 1A: Candidate admitted to transplant center and has at least one of the following devices or therapies in place: Mechanical circulatory support LVAD, RVAD, BiVAD – may be listed for 30 days once stable, drops to 1B after 30 days Artificial heart IABP ECMO Mechanical circulatory support with objective evidence of device-related complication Continuous mechanical ventilation Continuous infusion of single high-dose or multiple inotropes with continuous hemodynamic monitoring of LV filling pressures Status 1B: Candidate must have one of the following devices or therapies in place: LVAD or RVAD Continuous infusion of inotrope(s) Status 2: Candidates that do not meet the criteria for 1A or 1B are considered Status 2 Status 7: Candidates that are temporarily unsuitable are placed on the Status 7 list Treatable disease Social situation When a patient matches blood type, they are then matched using the following criteria: age, body size (generally within 20% of donor), time on the wait list, severity of illness, and geographic distance between the donor hospital and the transplant center (measured in increasing 500 mile distances from the donor hospital). This system is regularly reviewed and revised with input from a wide variety of interested parties including transplant professionals, recipients, and donor families. Transplant coordinators/surgeons are called every time a potential match becomes available for their patient. When a patient is matched, they are called into the hospital – a backup candidate is also called. Donor organ evaluation continues as the procurement team is sent to harvest the organ – organ visualized prior to removal and some are denied at the last minute. The donor heart is resected with the right atrium intact. It is preserved in a cardioplegic solution designed to optimize myocardial metabolism or prevent cell damage (KCl) and packed in ice. The donor heart must be transplanted within 4 to 6 hours. The prognosis for heart transplant patients has increased over the past 20 years, and as of 2012 survival rates are 86.2% (females) to 88% (males) at 1 year, 77.2% (females) to 79.3% (males) at 3 years, and 69% (females) to 73.2% (males) at 5 years.[ii] The denervated heart has a loss of parasympathetic control – no mechanism to slow conduction rate or velocity (HR almost always 90-110); no quick mechanism to respond to changes in filling pressures (hypotension will lead to catecholamine release and eventual increase in HR); exercise – long, slow warmups recommended (10-15 minutes); transplant patient do not have chest pain. Postoperative complications include bleeding, RV failure, hypovolemia, acute rejection, drug reactions/side effects, and infection. The healthy heart is not used to working against high pulmonary artery pressures and starts to fail, usually between days 2 to 4, characterized by elevated CVP. Isoproterenol increases HR to unload RV, inhaled nitric oxide decreases pulmonary artery pressures – occasionally need to implant RVAD and slowly wean. MVC-AACN Newsletter 29 There are several types of organ rejection. Hyperacute rejection occurs a few minutes after the transplant when the antigens are completely unmatched – wrong cross-match. Acute rejection may occur any time from the first week after the transplant to 3 months afterward. All recipients have some amount of acute rejection. Chronic rejection can take place over many years. The body’s constant immune response against the new organ slowly damages the transplanted tissues or organ. Signs and symptoms include: the organ’s function may start to decrease; general discomfort, uneasiness, or ill feeling; pain or swelling in the area of the organ (rare); fever (rare); flu-like symptoms including chills, body aches, nausea, cough, and shortness of breath; general malaise – first clue to change in cardiac function! R Rejection is graded: 0 (none); 1 (mild) – interstitial and/or perivascular infiltrate with up to one focus of myocyte damage; 2 (moderate) – two or more foci of infiltrate with associated myocyte damage; 3 (severe) – diffuse infiltrate with multifocal myocyte damage with +/- edema or +/- hemorrhage or +/vasculitis.[iii] The strategy for treating rejection is based on the severity of rejection and the patient’s ability to tolerate the treatment – renal function can be a limiting factor. Most often, it involves increased dosing of immunosuppressive drugs or addition of a temporary agent. Patients may or may not be hospitalized based on the scenario. Postoperative nursing interventions include monitoring for bleeding and RV failure; support – minimize blood products if possible, respond to changes in RV function (pulmonary dilators, inotropes, mechanical support); and strict adherence to immunosuppressive therapy – blood levels same time every day. There are four categories of immunosuppression drugs. Category I: Steroids – nonspecifically inhibit inflammatory response Category II: Antiproliferatives – inhibit expansion of cell lines that modulate rejection, work primarily on T and B cells Category III: Other categories – work by blocking humoral response such as cytokine production Category IV: Antibodies – monoclonal, polyclonal. Consistency in timing of drugs is very important. The patient’s home schedule should be followed as closely as possible. Steroids include methylprednisolone – used initially and pulse dosed with rejection episodes, high dose weaned over time; and prednisone. Side effects include round face, hyperglycemia, bone weakening, obesity, increased cholesterol, muscle weakness, cataracts, mood swings, and infection. Antiproliferatives include: Azathioprine (Imuran) – T cells and B cells, dosage titrated to WBC of 5000/cc, with side effects of low WBC, bone marrow suppression, liver abnormalities, and nausea; Mycophenolate mofetil (Cell Cept) – T cells and B cells with BID dosing and side effects of nausea, diarrhea, and low WBC. Other categories include: Cyclosporine (Neoral or Sandimmune or CsA) – humoral response inhibitor, BID dosing titrated to trough blood levels, side effects of renal impairment, headache, tremors, high potassium, photosensitivity, thickening of the gums, and increased hair growth; Tacrolimus (Prograf or FK506) – inhibits cytokine production, BID dosing titrated to trough blood levels, side effects of renal impairment, high potassium, seizures, headache, tremor, and hypertension. Monoclonal antibodies are directed at specific antigens, so they are less toxic than polyclonal antibodies. OKT3 is the most common – may be used for short periods if renal function is questioned (decrease dose of antiproliferatives), used to treat rejection. Polyclonal antibodies – animal antithymocyte antigen (ATG) (rabbit or horse) – very potent antibodies that attack all lymphocytes, reserved for steroid-resistant rejection, and always given in ICU due to high risk of reaction. Supportive drugs include diuretics, antibiotics (Bactrim DS – careful with renal impairment!), aspirin, calcium (prevent drug-induced osteoporosis), and GI prophylaxis (secondary to steroids). MVC-AACN Newsletter 30 Transplant precautions should include use of a positive pressure room – air is filtered and blows out to the hallway. Otherwise use standard precautions with a few considerations – anyone with a fever or upper respiratory infection may not enter the room (if it is essential for staff to enter the room to provide care for these patients, the staff member should wear a surgical mask); anyone entering the room must disinfect their hands with an alcohol-based waterless agent or antimicrobial soap; use only the stethoscope in the patient’s room; communal patient care equipment is disinfected prior to bringing it into the patient’s room; patients are assigned to a single room; keep the number of visitors to a minimum; and flowers are not allowed in the room. Long term complications include cardiac allograft vasculopathy – can be a slow, chronic process; coronary arteries become thickened and hard; impairs coronary perfusion of donor heart; and eventually leads to heart failure – treatment is transplant. Most long-term complications are related to drugs – infection from immunosuppression, renal impairment, hypertension, diabetes, high cholesterol, cancer, osteoporosis, and cataracts. Eleven exhibitors supported the conference: Abbott Nutrition, AccuVein, Bard Medical, ConvaTec, Dale Medical Products, Eloquest Healthcare, Mallinckrodt Pharmaceuticals, New England Organ Bank, Nihon Kohden, NxStage Medical Inc., and the United States Army Nurse Corps Recruiting Company. The following raffle prizes were awarded: Membership (one year national AACN and Merrimack Valley Chapter) – Gail Landers CCRN/PCCN certification/recertification – Kristen Richards NTI 2015 (one-day complimentary registration) – Wendy Pelletier Fall program – Jane Parris Exhibitor form (fall program) – Mary Ann McNamara Extra fall program raffle for participants in overflow seating – Gretchen Lord Stay tuned for our fall 2015 program! [i] Kappetein AP, Head SJ, Genereux P, et al. Updated Standardized Endpoint Definitions for Transcatheter Aortic Valve Implantation. J Am Coll Cardiol. 2012;60(15):1438-1454. [ii] Heart Disease and Stroke Statistics--2012 Update The American Heart Association. Retrieved 18 August 2014. [iii] The International Society for Heart and Lung Transplantation (ISHLT) System for Grading Rejection: Revised Grading:(2004). MVC-AACN Newsletter 31